Patient History

This 30 year-old female presented with low back pain that started 6 months ago. Activity makes her pain worse. She reports back pain as 8/10 and thigh pain as 5/10 without pain distal to the knee. Her Oswestry Disability Index is 50%. The patient does not have a history of trauma.

Examination

On physical examination, the patient reported low back tenderness and lumbar pain with range of motion. She is neurologically intact. 0/5 Waddell signs.

Case Discussion

Doctor Polly presents a case of a 30 year-old female with axial low back pain with radiation to the thighs. The MRI demonstrates L4-L5 degenerative disc disease (confirmed by discography) and the flexion-extension X-rays demonstrate a minimal retrolisthesis of L4 on L5 in extension. This patient has had symptoms for 6 months.

Prior to offering any surgical treatment, I would recommend maximal conservative management with truncal strengthening, physical therapy and aqua therapy. If the patient is above ideal body weight, I would recommend weight loss. Should the patient fail all conservative measures, I would consider surgery to treat the L4-L5 segment only as a last resort.

My preference is a posterior procedure. The patient is of child-bearing age, and thus I would prefer to avoid an anterior operation (i.e. artificial disc or ALIF) through the abdominal wall musculature.

I would consider 3 surgical options: a direct lateral approach, a posterolateral fusion, or a TLIF. Of these options, I would choose a minimally invasive TLIF. In my hands, this procedure has the least amount of morbidity to the paraspinal musculature, while effectively immobilizing the abnormal segment with a high potential for fusion through the interbody space. The interbody fusion directly addresses the diseased disc and the posterior pedicle fixation addresses the minimal retrolisthesis.

Author's Response

Optimizing nonoperative care is an oft repeated mantra that we all dogmatically espouse, especially in training programs. But what does that really mean? Should patients lose their jobs because they cannot work? Should they sign up for a weight loss program that is pragmatic and doable?

New data is beginning to suggest that after 8-weeks of effort in PT, no significant additional benefit is discernible by Oswestry scores, etc. This patient had done core stabilization, a normal BMI, and was having job Impairment in spite of trying all of the appropriate nonop care. I find it a significant challenge about when to pull the trigger and do the surgery (and then there is the issue of how long does it take to get the person approved, scheduled, and into the OR).